Thoughts on job offer

[Iapetus]

Wanted to get your thoughts on an offer I received. Seems decent at face value but am I overlooking anything. This would be first job out of residency.

-Midwest location
-Smaller rural hospital affiliated with big hospital system; I’m from area so location is good for me
-No current psychiatrist, IOP and PHP on site ran by social work and contracted physician
-Strictly outpatient, no call, no weekends
-Possibility of flexible work schedule which I would probably do 4-10s
- as no psychiatrist there, told by administration I could set up largely how I see fit. My thought would be 30 min follows, 60 minutes new. With some psychotherapy add on codes. (Anything to consider here?)
-270k total comp base. Essentially was told I could work numbers how I see fit over 3 year contract (I.e 30k signing and 260k/base salary)
-Minimum RVU threshold 3600
-Anything over threshold will pay per RVU $30-35.
-20 days vacation, 5 CME and 7 holidays

Anything else I should be considering or asking about?

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[splik]

the wRVU for exceeding your threshold is extremely low. For 270k @3600 wRVU is equivalent to $75 per RVU which is high (thus good). The median wRVU for psych is about $67. $30-35 is hardly incentive to be more productive.

 

[Iapetus]

the wRVU for exceeding your threshold is extremely low. For 270k @3600 wRVU is equivalent to $75 per RVU which is high (thus good). The median wRVU for psych is about $67. $30-35 is hardly incentive to be more productive.

I don't disagree, as I stated the same thing. They essentially stated that them overpaying for the initial 3600 balances it out. When I do the math, I don't entirely disagree as 4200 RVUs would generate $288000 on their model vs $281400 for straight productivity. I think my hang up, is how many wRVUs can I realistically expect to produce staying busy but not working myself to burnout. In 3rd year of residency I was comfortably seeing 12-14 follow ups with 1-2 new in an 8 hour day. I figure if I do some psychotherapy and use some add on codes it would not be difficult to generate at least the above if not more.

 

[nexus73]

Is there an expectation you can screen referrals? If there is not good access to community mental health center, the PCPs will expect they can refer any psych related patient to you. Including severe schizophrenia, borderline, autism with behavioral problems etc. Which is probably not ideal if it’s just you and a medical assistant in an office. Will you have a nurse? Social work? Therapist in the office?

 

[robellis]

If you’re the only psychiatrist, it’s likely you will soon have a high volume which then means the wrvu bonus becomes important. 35 per wrvu is very low as was previously mentioned. If you are going to artificially limit yourself to only seeing up to the wrvu bonus threshold then obviously it’s a good deal but Then you will essentially be turning away new patients which they may not like you to do.

 

[dl2dp2]

If location is good, all other considerations are less important at least for the time being, as you have no relevant competing offers.

RVU numbers can always be negotiated down the line, but as a pitch you can say if you go up on it I'd be super incentivized to make you more money, and see if this makes it stick. Both sides know that at the current base it's not likely you'll work very hard.

Rural hospitals often have carve outs. Unless you see their books it'd be unclear how much indirects they are making off of you.

 

[TexasPhysician]

The contract should have in writing how long you get per follow-up and per eval. Double bookings not allowed. This is a fine job if you aren’t trying to be very busy. If you are aiming for productivity, this isn’t the contract for you.

 

[Merovinge]

Malpractice - occurrence based or will you need to provide a tail? Most have a certain number of years to be covered and it's not very expensive but still a consideration. 401k matching? Any additional retirement plans? Any disability insurance (you probably need your own but good to know about group)?

Are you provided a full time nurse? How is your scheduling done? Are you required to see all-comers or are there diagnosis you can exclude at your preference? How do they respond when patients are demanding controlled substances that are inappropriate? Who covers your patients when you are on vacation if you are the only psychiatrist?

Like everyone is saying, if you anticipate around 3600 wRVUs and want something pretty chill to start it's fine but not amazing for a rural midwestern location. A colleague I know who just finished training started at >350k for a rural midwestern, all outpatient, no call, but I do not know his incentive/vRVU structure. Another guy I know in rural Tennesse is a bit over 350k as well.

 

[Sushirolls]

Non-compete?

 

[Stagg737]

Are the RVUs based on billed or collected?

Less relevant but 32 total paid days off?

 

[the5thelement]

I knew a guy who signed up in a rural hospital on $280,000 salary , they dropped the salary to $180,000 next year saying he wasnt "productive" enough.
I have been weary of anything to do with "RVUs" ever since !

 

[AD04]

I knew a guy who signed up in a rural hospital on $280,000 salary , they dropped the salary to $180,000 next year saying he wasnt "productive" enough.
I have been weary of anything to do with "RVUs" ever since !

My guess is he didn't know how to bill. Or the administration isn't honest. If you want to get paid by RVUs, I would suggest to:

1. learn billing

2. keep track of your productivity (at least on a ballpark basis) and compare to what the hospital reports

 

[TexasPhysician]

I knew a guy who signed up in a rural hospital on $280,000 salary , they dropped the salary to $180,000 next year saying he wasnt "productive" enough.
I have been weary of anything to do with "RVUs" ever since !

Then you leave the next year when the salary drops. Jobs outside of academia/government are not forever. They will come and go. You need to be prepared to leave. I really enjoyed one of my addiction medicine jobs. It is now bankrupt and gone.

This is one of the reasons I started my own practice. I can make the changes to survive and if not, it is my own fault. Otherwise stability is best at the VA or academia.

 

[Iapetus]

Is there an expectation you can screen referrals? If there is not good access to community mental health center, the PCPs will expect they can refer any psych related patient to you. Including severe schizophrenia, borderline, autism with behavioral problems etc. Which is probably not ideal if it’s just you and a medical assistant in an office. Will you have a nurse? Social work? Therapist in the office?

Will have some level of screening, however probably will take a mix of everything. There is community mental health located nearby as well. Initially will primarily be MA and myself. Plan to expand to have therapist in office as well, however they want to establish psychiatrist first. I asked about nursing support and basically got a "maybe."

Malpractice - occurrence based or will you need to provide a tail? Most have a certain number of years to be covered and it's not very expensive but still a consideration. 401k matching? Any additional retirement plans? Any disability insurance (you probably need your own but good to know about group)?

Are you provided a full time nurse? How is your scheduling done? Are you required to see all-comers or are there diagnosis you can exclude at your preference? How do they respond when patients are demanding controlled substances that are inappropriate? Who covers your patients when you are on vacation if you are the only psychiatrist?

Like everyone is saying, if you anticipate around 3600 wRVUs and want something pretty chill to start it's fine but not amazing for a rural midwestern location. A colleague I know who just finished training started at >350k for a rural midwestern, all outpatient, no call, but I do not know his incentive/vRVU structure. Another guy I know in rural Tennesse is a bit over 350k as well.

I'll need to double check the malpractice provided, good point. 401k match will match contributions up to 6%. Also access to 457b. Long term disability of 60% salary. Discussed full time nurse and essentially got a maybe, any thing I should highlight to help sell why I would need one full-time? As far as coverage on vacation, their is a central behavioral health triage set up in the system outside office hours. As far as doing med refills, patient questions etc the plan is either hire an extender or have outpatient psychiatrists at other hospital in system cover. This part was a sticking point for me.

Non-compete?

Yes, but nothing really inside the area I'd want to work at anyway. If I left I'd be outside the confines of the non-compete area.

Are the RVUs based on billed or collected?

Less relevant but 32 total paid days off?

Based on billed, not collected. Yep 32 total days if you include CME days.

 

[Merovinge]

If you're doing full-time outpatient with high hundreds to low thousand of total patients in clinic for nearly 40 hours a week without a nurse, that would be so unbelievably miserable. You're patients will call for any number of things and if you have to deal with each call you can easily add 15 hours to that work week of unbillable work. I would never consider that setup for an already low paying rural psychiatry salary.

 

[hebel]

If you're doing full-time outpatient with high hundreds to low thousand of total patients in clinic for nearly 40 hours a week without a nurse, that would be so unbelievably miserable. You're patients will call for any number of things and if you have to deal with each call you can easily add 15 hours to that work week of unbillable work. I would never consider that setup for an already low paying rural psychiatry salary.

Could an MA/receptionist staff these, or do you really need a nurse?

 

[nexus73]

Could an MA/receptionist staff these, or do you really need a nurse?

An MA or receptionist isn’t trained to be answering patient medication questions, screening for symptoms, or over the phone risk assessment etc. It’s super risky to put them in this position.

 

[hebel]

An MA or receptionist isn’t trained to be answering patient medication questions, screening for symptoms, or over the phone risk assessment etc. It’s super risky to put them in this position.

Hmm, I could see the utility with a mega-high volume practice. I've worked at 7 different outpatient clinics in various settings and none of them ever had a nurse on staff.

 

[TexasPhysician]

Hmm, I could see the utility with a mega-high volume practice. I've worked at 7 different outpatient clinics in various settings and none of them ever had a nurse on staff.

Correct. I don’t have a nurse, so all questions come through me or staff creates an earlier follow-up.

If I had an insurance practice, I would schedule 3-5 follow-ups every hour, hire any many psychiatrists as possible, and utilize a nurse instead of ever answering questions myself. The time it would take to return 1 phone call is a loss of a 99213 or higher.

 

[calvnandhobbs68]

Correct. I don’t have a nurse, so all questions come through me or staff creates an earlier follow-up.

If I had an insurance practice, I would schedule 3-5 follow-ups every hour, hire any many psychiatrists as possible, and utilize a nurse instead of ever answering questions myself. The time it would take to return 1 phone call is a loss of a 99213 or higher.

Yep. Just a thought about this I've had lately, if it's something that'll take longer than 5 minutes, offer to convert it into a video appointment or else have them reschedule since you can actually bill for telepsych for the time being. You could literally just put them on Zoom, tell them this is going to be billed as a 15 minute appt and then bill it as a 99213, etc. Anyone ever actually tried doing this?

 

[TexasPhysician]

Yep. Just a thought about this I've had lately, if it's something that'll take longer than 5 minutes, offer to convert it into a video appointment or else have them reschedule since you can actually bill for telepsych for the time being. You could literally just put them on Zoom, tell them this is going to be billed as a 15 minute appt and then bill it as a 99213, etc. Anyone ever actually tried doing this?

In an insurance practice, that will require a co-pay typically. Patients hate co-pays. They will argue that it is just a quick question that should have been explained in the appointment. I’m with you that we should always be paid for our time, but it really angers patients. I don’t make any calls unless the issue seems urgent.

 

[FlowRate]

Just echoing other folks that you need to define how much of your work day is devoted to direct patient care. I'd want some charting/admin/communications time, especially since you have rather limited supports. My other thought was that you should not lower repeating contractual remuneration for one-time stipends unless you have a particularly good reason to do so. If you take a 30k signing bonus and reduce your salary by 10k then you're already behind if you work a fourth year at that job...

 

[Merovinge]

Correct. I don’t have a nurse, so all questions come through me or staff creates an earlier follow-up.

If I had an insurance practice, I would schedule 3-5 follow-ups every hour, hire any many psychiatrists as possible, and utilize a nurse instead of ever answering questions myself. The time it would take to return 1 phone call is a loss of a 99213 or higher.

My current employer has a new policy requiring all messages returned within 48 hours. Many of my patients call about medications, wanting to change them, concerns they have regarding their children's behaviors, etc. Many do not want this converted to an apt, although the ones on public aid that have no copays likely would, currently my employer does not bill visits in this manner. I recently had a new consult that has called literally 12 times in the first 4 weeks follow their initial visit. If I did not have a nurse for my medicaid CAP clinic (only slightly different flavor than OPs likely high number of medicaid/medicare adult clinic), I would probably need to check myself in somewhere.

Now when I can open a cash pay practice someday, I absolutely do not plan on having a nurse, but that's very different than working rural non-profit outpatient psych.

 

[calvnandhobbs68]

My current employer has a new policy requiring all messages returned within 48 hours. Many of my patients call about medications, wanting to change them, concerns they have regarding their children's behaviors, etc. Many do not want this converted to an apt, although the ones on public aid that have no copays likely would, currently my employer does not bill visits in this manner. I recently had a new consult that has called literally 12 times in the first 4 weeks follow their initial visit. If I did not have a nurse for my medicaid CAP clinic (only slightly different flavor than OPs likely high number of medicaid/medicare adult clinic), I would probably need to check myself in somewhere.

Now when I can open a cash pay practice someday, I absolutely do not plan on having a nurse, but that's very different than working rural non-profit outpatient psych.

Thanks for reminding me about something to ask about for employers in the future. No thanks, I'm not getting obligated to return 3 phone calls a week within 48 hours each for the same patient.

Once it gets over 2 calls between appointments, I just tell people lets make an appointment to talk about your concerns and we'll talk about them at that time. At least them somebody can get paid.

 

[sykemama]

Bump.

What kind of offers (salary, call, hours, etc. and the region) are current PGY4s getting for outpatient psychiatry for after residency?

 

[Psychresy]

What's the best set up to get yourself to 400k?

 

[FN9]

What's the best set up to get yourself to 400k?

4 10s and a side gig moonlighting

 

[J ROD]

If you are a guy wanting to show up and see what you see and make that upper 200's then you got a decent deal. I would still argue for higher than 35 per wrvu. I enjoy my deal where I get what I bill and I have no limit. I eat what I kill. I work hard though. I see as many folks as I can all day everyday and do not take days off. Work extra weekends etc.

Got to know what you like. Plus, it is important to know the support staff around you and expectations moving forward. Do they want you just there to see psych patients or drive some business and money making.

 

[Mass Effect]

If you are a guy wanting to show up and see what you see and make that upper 200's then you got a decent deal. I would still argue for higher than 35 per wrvu. I enjoy my deal where I get what I bill and I have no limit. I eat what I kill. I work hard though. I see as many folks as I can all day everyday and do not take days off. Work extra weekends etc.

Got to know what you like. Plus, it is important to know the support staff around you and expectations moving forward. Do they want you just there to see psych patients or drive some business and money making.

Are you seeing high-functioning patients? I would enjoy an eat-what-you-kill setup if I was seeing the worried well, but the patient population I'm currently seeing would kill me in an EWYK model.

 

[deleted310399]

Wanted to get your thoughts on an offer I received. Seems decent at face value but am I overlooking anything. This would be first job out of residency.

-Midwest location
-Smaller rural hospital affiliated with big hospital system; I’m from area so location is good for me
-No current psychiatrist, IOP and PHP on site ran by social work and contracted physician
-Strictly outpatient, no call, no weekends
-Possibility of flexible work schedule which I would probably do 4-10s
- as no psychiatrist there, told by administration I could set up largely how I see fit. My thought would be 30 min follows, 60 minutes new. With some psychotherapy add on codes. (Anything to consider here?)
-270k total comp base. Essentially was told I could work numbers how I see fit over 3 year contract (I.e 30k signing and 260k/base salary)
-Minimum RVU threshold 3600
-Anything over threshold will pay per RVU $30-35.
-20 days vacation, 5 CME and 7 holidays

Anything else I should be considering or asking about?

Questions I would atleast start with -

1) How's the area to live in ? Can you live in a more desirable city maybe an hour away and do something like 1 day in clinic and 3 Tele days from home ( all 10s ) ?
2) How busy is the practice and how much of a chance do you have of making over 3600 RVUs without burning out ?
3) What is the support staff like ( this is critical ) ?
4) How much does the administration support you and just let you do your work ( again critical ) ?
3) How badly do they need you ( which would indicate how negotiable anything is ) ? You said there is no Psychiatrist . Why ? Have they had trouble attracting someone because of the location or is it something more sinister ?

 

[J ROD]

Are you seeing high-functioning patients? I would enjoy an eat-what-you-kill setup if I was seeing the worried well, but the patient population I'm currently seeing would kill me in an EWYK model.

Nope. I am inpatient. I have several NPs that are pretty good. They do the notes and I get to manage patients.

 

[Splenda88]

Nope. I am inpatient. I have several NPs that are pretty good. They do the notes and I get to manage patients.

What do you mean by that?

Since they are 'pretty good' (your words here), I guess they can replace psychiatrists...

 

[Mass Effect]

What do you mean by that?

Since they are 'pretty good' (your words here), I guess they can replace psychiatrists...

Wow that seemed like a leap.

 

[Sushirolls]

Wow that seemed like a leap.

That's the leap that is happening and playing out in Big Box shops.

But the work flow of them doing notes and the Psychiatrist managing patients is interesting. Not sure what that means. Interesting to hear the workflow. I can only conceptualize a scribe.

 

[Mass Effect]

That's the leap that is happening and playing out in Big Box shops.

I was referring to the poster's assumption that because the NPs were good it meant they can replace psychiatrists. I don't think the OP was implying the NP can take over for psychiatrists.

 

[Stagg737]

Nope. I am inpatient. I have several NPs that are pretty good. They do the notes and I get to manage patients.

This seems pretty nice, but I always question EWYK in inpatient settings. I've seen this a couple times and it seems that churn control sometimes takes priority over patient care.

Are you seeing high-functioning patients? I would enjoy an eat-what-you-kill setup if I was seeing the worried well, but the patient population I'm currently seeing would kill me in an EWYK model.

Same. If you've got 75%+ patients who are generally stable this would be pretty ideal (lots of ADHD + mild depression/anxiety). Doing this with SMI/SPMI or a lot of personality disorders and this sounds miserable.

 

[J ROD]

What do you mean by that?

Since they are 'pretty good' (your words here), I guess they can replace psychiatrists...

some psychiatrists.....

 

[Attending1985]

Wanted to get your thoughts on an offer I received. Seems decent at face value but am I overlooking anything. This would be first job out of residency.

-Midwest location
-Smaller rural hospital affiliated with big hospital system; I’m from area so location is good for me
-No current psychiatrist, IOP and PHP on site ran by social work and contracted physician
-Strictly outpatient, no call, no weekends
-Possibility of flexible work schedule which I would probably do 4-10s
- as no psychiatrist there, told by administration I could set up largely how I see fit. My thought would be 30 min follows, 60 minutes new. With some psychotherapy add on codes. (Anything to consider here?)
-270k total comp base. Essentially was told I could work numbers how I see fit over 3 year contract (I.e 30k signing and 260k/base salary)
-Minimum RVU threshold 3600
-Anything over threshold will pay per RVU $30-35.
-20 days vacation, 5 CME and 7 holidays

Anything else I should be considering or asking about?

What is a minimum Rvu threshold? If you don’t meet this are you required to pay money back?